Cross-national comparison of three latent classes of young men who attempted suicide in China and Britain

doi:10.21203/rs.3.rs-3406639/v1

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Cross-national comparison of three latent classes of young men who attempted suicide in China and Britain

https://doi.org/10.21203/rs.3.rs-3406639/v1

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Background

Suicide attempts are critical predictors of suicide. Developing typologies of suicide attempt may indicate new prevention strategies, which have not been investigated by comparing developed and developing countries. Therefore, we aim to compare the relationship between suicide attempt and mental disorder and develop a typology of suicide attempts among Chinese and British young men.

Methods

Cross-national surveys of 2046 British and 4238 Chinese men aged 18 − 34 years old in households, 2011—2013. Hierarchical multinomial regression models were used to investigate associated factors. Latent class analysis (LCA) to identify homogeneous subgroups.

Results

Prevalence of suicide attempt was higher among Chinese (8.3%, 95% CI: 7.4%−9.2%) than British men (6.6%, 95% CI: 5.5%−7.7%) (OR: 1.27, 95% CI: 1.03–1.57, p = 0.025). Depression was not independently associated with suicide attempts among Chinese men, while anxiety played a vital role in both countries. Three latent classes identified a subgroup more prevalent among Chinese men featuring weakened social bonds in the absence of mental disorder, and another subgroup more prevalent among British men characterizing impulsivity, childhood maltreatment, substance misuse, and chaotic lifestyles.

Conclusions

Further research could test the clinical applicability of this typology in the assessment of men at risk of future suicide and choice of treatment and preventive interventions. Because Class 2 featured by weakened social bonds is more prevalent among Chinese men, research could stablish whether recent improvements in access to crisis services in China have been effective.

Suicide Attempt

Transcultural Psychiatry

Psychiatric Disorder

Social Deprivation

Childhood Experience

Suicide accounts for 1.4% of all deaths worldwide and is the fourth leading cause of death between 15–29 years [1]. Suicide attempts are key predictors of future suicide and strongly associated with depression, psychosis, anxiety [2–5], addictive disorders [6], certain social-demographic factors, including educational level [7, 8], and traumatic life events [9]. Risk factors for suicide attempts differ between Eastern and Western countries, with life stress and low social-economic status thought more associated with suicide in Eastern than in Western countries (15–17). However, the difference of suicide attempt between Eastern and Western countries still need to be further explored because most cross-national studies have been conducted in neighbouring countries, such as the Western Pacific Region or Europe [7, 10–12]. Cross-national studies carried out in very different cultural settings may help in providing more comprehensive understanding of etiological mechanisms to aid policy-making for prevention, and also whether the same principles apply globally [13]. For example, should China apply the same principles to prevention as in Europe and North America? Or are there etiological mechanisms that are specific to China, requiring specific, culturally related interventions?

The sex ratio of suicide rate has changed inversely in recent years in China [14–16]. The male: female ratios of age-standardized suicide rates had been above 1.0 in 2000 and increased to 1.56 in 2017 in China [17], so that between 2009 and 2011, there was a higher suicide rate among young men compared to young women in the under 35 age group [15]. This increase among young men indicates the importance of focusing on this young male subgroup in China to investigate what factors have contributed to the suicide attempt of males. However, a key research problem when comparing different countries and impact of cultural backgrounds is the considerable heterogeneity between different studies [18, 19]. Few comparisons between Eastern and Western countries have used similar methods or attempted to control for similar confounders. We are not aware such an approach has been used in any previous cross-cultural comparisons of suicide attempts in a Chinese and a British population.

We aim to compare prevalence and associated factors for suicide attempts between young men in China and Britain using the same questionnaires and a similar community-based random sampling method, and then test whether a typology of suicide attempts can be identified according to latent classes of associated factors in a combined cross-national sample, at last compare identified classes between Chinese and British men.

Study population

The survey in Great Britain was carried out in 2011 based on random location sampling (Fig. 1). This advanced form of quota sampling reduces biases when interviewers chose the locations to sample. Individual sampling units (census areas of 150 households each) were randomly selected from British regions in proportion to their population to derive a representative sample of young men 18–34 years from England, Scotland, and Wales. More details of the sampling procedures have been described in previous study [20]. The survey in Chengdu, Sichuan Province, China, was conducted in two waves in 2012 and 2013 based on random location sampling, as used in the British survey, using a similar method quota sampling. We applied a multi-stage stratified random sampling method to divide Chengdu city and surrounding rural areas into three concentric circles according to economic level: (1) central city areas; (2) the suburbs; (3) rural areas. Our sampling strategy differs depending on the three concentric circles and the administrative organization of the household (Fig. 1)[21]. There were 4238 Chinese young men selected and surveyed. The survey was conducted by trained interviewers who provided pencil and paper questionnaires to participants and retrieved after completion (about 40 minutes). The self-administered questionnaire used in the British survey was translated into Mandarin, then independently back-translated into English to ensure equivalence with the English version. Participants were young men 18–34 years old who received £5 (Britain) or a gift equal to £5 (Y50 in China). In order to ensure representativity of the sample, the surveys in Britain and China were weighted according to RIM weighting and probability weighting, respectively [21]. All statistical analyses were based on weighted data.

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. This study was approved by Medical Ethics Committee of Sichuan University (No: 2011003). Written informed consent was provided by all the participants during data collection.

Measures

Socio-demographic variables

Socio-demographic variables included age, ethnicity (Han Chinese or British white majority or ethnic minority), employment status, education level, living alone or not, and no close relationship. Education level was identified by “at what age did you finish your full-time education?” “Never went to school” and “under 12” were classified as low level, “13–18” was classified as middle level, “19+” and “still attending college/university” were classified as high level.

Mental health assessment

The Psychosis Screening Questionnaire (PSQ) was used to screen participants for psychosis, and criteria were met when positive items ≥ 3 [22]. The PSQ had a sensitivity of 96.9%, a specificity of 95.3%, a positive predictive value of 91.2%, and a negative predictive value of 98.4% [21, 22]. The Hospital Anxiety and Depression Scale (HADS) was used to screen anxiety and depressive disorders with the criteria of score > 11 in the past week [23]. The Cronbach’s alpha coefficient of anxiety subscale and depression subscale was 0.80 and 0.81, respectively [24]. Addictive disorders: the alcohol use disorders identification test (AUDIT) with a score of ≥ 20 was used to identify alcohol dependence. The Cronbach’s alpha of the AUDIT was 0.93 [25]. The drug use disorders identification test (DUDIT) with a score of ≥ 6, was used to identify drug misuse disorder. The Cronbach’s alpha coefficient was 0.80 [26].

Suicide attempt

Attempted suicide was reported in response to ‘Sometimes when we are feeling very unhappy or hopeless, we may get thoughts of harming ourselves. Have you ever tried to kill yourself/made a suicide attempt?’ and coded yes, no, or don’t know.

Lifetime Traumatic events

Child maltreatment was identified by asking “Have you ever suffered from any of these problems or events before the age of 16 (bullying, witnessing violence in the home, witnessing parents/careers fighting, sexual abuse/assault, physical abuse, neglect, serious/life threatening injury)?” Child maltreatment was identified if any were endorsed. Adult traumatic events were identified by asking “Have you ever suffered from any of these problems or events since the age of 16 (been injured as a result of physical attack, a victim of stalking, violence at work, domestic violence in the home from a partner, sexual assault, serious/life threatening injury, separation due to marital difficulties or breakdown of a steady relationship, death of your husband/wife or partner or child, being fired or made redundant, homelessness, serious money problems, and made bankrupt)?”. Traumatic events were identified as positive if any were endorsed.

Impulsivity

Impulsivity was identified according to the third question of antisocial personality disorder from the Structured Clinical Interview for DSM-IV personality disorders (SCID-II) screening questionnaire, by asking “Now thinking of the time, since you were 15, do you often do things on the spur of the moment without thinking about how it will affect you or other people?” White British (1699, 83.2%) was identified as majority, and others were identified as minority in UK. Ethnic Han (4111, 97.4%) was identified as majority, and other ethnicities were identified as minority in China. Physical illness/disability was identified by asking “Do you have any longstanding (1 year or more) physical illness(es) or physical disabilities?”

Statistical analyses

We used logistic regression to explore associations between each variable and suicide attempts among British and Chinese men adjusted for age. If the association between variable and suicide attempt was significant at an alpha level of 0.05, it was selected and then entered in subsequentmultivariate logistic regression under mutual adjustment to identify factors associated with suicide attempts according to nationality.

Hierarchical multinomial regression models with independent variables of suicide attempts were used to investigate 1) whether nationality was independently associated with suicide attempt, 2) the extent to which variables affected associations between suicide attempt and nationality, stepwise. Variables associated with suicide attempt in multivariate logistic regression were included in hierarchical multinomial regression models. Six regression models were applied to adjust for covariates: model 1, without adjustment; model 2, adjusted for demographic and social factors; model 3, model 2 with additional adjustment for traumatic factors; model 4, model 3 with additional adjustment for impulsivity; model 5, model 4 with additional adjustment for addictive behaviours; Model 6: model 5 with additional adjustment for psychiatric disorders. Change in magnitude of association between suicide attempt and nationality was quantified using the percentage explained by each category of variables: (B_n - B_n−1)/B₁. B_n is the B coefficient of multinomial regression model N. B_n−1 coefficient is the B coefficient of multinomial regression model N-1. B₁ coefficient is the B coefficient of multinomial regression model 1.

Latent class analysis (LCA) was conducted to identify homogeneous subgroups. Models with numbers of classes from 2 to 5 were evaluated to determine optimal number of latent classes using risk variables for suicide attempt previously identified by multinomial regression. Model selection was based on information criteria, Lo-Mendell-Rubin test (LMRT), and entropy. Information criteria include the Akaike’s information criterion (AIC), Bayesian information criterion (BIC), and sample-size adjusted BIC (aBIC), where lower values indicate better model fit. Entropy with value > 0.80 indicates that the accuracy of classification is above 90% [27]. The LMRT and the Bootstrap likelihood ratio test (BLRT) with p-value < 0.05 indicate significant improvement of model fit compared to the model with one less class [28]. Finally, we drew a line chart to present model probabilities of response for included factors. Univariate logistic regression was used to find which variables discriminated latent classes.

All tests were two-tailed and an alpha level below 0.05 was considered statistically significant. LCA was carried out in Mplus 8.3. All other analyses were performed with the statistical package SPSS (version 25.0).

Prevalence of suicide attempt

The cross-national sample included 2046 British (age, Mean ± SD: 24.76 ± 5.01) and 4238 Chinese (age, Mean ± SD: 26.65 ± 4.96) young men aged 18 − 34 years old (t = 14.03, p < 0.001). Prevalence of suicide attempts was higher among Chinese (8.3%, 95% CI: 7.4%−9.2%) than British (6.6%, 95% CI: 5.5%−7.7%) men (OR: 1.27, 95% CI: 1.03–1.57, p = 0.025).

Associated factors of suicide attempt among British and Chinese young men

Following adjustment for age, suicide attempts among both Chinese and British men were associated with lower education level, physical illness, child maltreatment, traumatic events, impulsivity, alcohol dependence, drug misuse, anxiety disorder, depression and psychosis through univariate logistic regression. Unemployment showed associations only among British men; living alone and no close relationship showed associations only among Chinese men. Ethnicity, unemployment, education, adulthood traumatic events, drug misuse and anxiety differed between British and Chinese young men for suicide attempts in univariate logistic regression (details in supplemental materials, Table S2). Missing data for each variable are listed in supplemental materials, Table S1.

After including all significant associated factors of suicide attempt listed in Table S2, unemployment, education, impulsivity, alcohol dependence, and drug misuse were no longer significant independent associated factors among British men. Education, living alone, adult traumatic events, drug misuse and depression were no longer significant independent associated factors of suicide attempt among Chinese men. Anxiety was no longer significantly different between British and Chinese men (Table 1).

Table 1

Association between suicide attempt and social factors, stress factors, impulsivity, addictive and psychiatric disorders, in Chinese and British young men aged 18–45 years.
Variables	British with suicide attempt ref: British without suicide attempt		Chinese with suicide attempt ref: Chinese without suicide attempt		Chinese with suicide attempt vs British with suicide attempt
Variables	n = 129 (6.6)	AOR (95% CI) ^a	n = 329 (8.3)	AOR (95% CI) ^b	AOR (95% CI) ^c
Age (years)	24.76 ± 5.01	1.02(0.96–1.08)	26.65 ± 4.96	0.99(0.96–1.03)	1.01(0.94–1.08)
Ethnicity (minority)	20 (15.5)	0.74(0.33–1.66)	6 (1.8)	0.55(0.18–1.65)	0.14(0.03–0.76) ^*
Unemployment	59 (48.4)	1.38(0.81–2.35)	43 (13.2)	0.87(0.55–1.35)	0.14(0.07–0.31) ^***
Education
High	31 (24.4)	0.10(0.00-5.67)	102 (32.8)	1.35(0.64–2.88)	0.10(0.01–1.63)
Middle	93 (73.2)	0.13(0.00-7.32)	182 (58.5)	1.22(0.59–2.55)	0.06(0.00-0.84) ^*
Low	3 (2.4)	Ref.	27 (8.7)	Ref.	Ref.
Living alone	22 (17.1)	0.85(0.39–1.86)	54 (16.5)	1.20(0.79–1.82)	1.16(0.46–2.91)
No close relationship	65 (58.6)	0.97(0.56–1.67)	147 (51.2)	1.34(0.99–1.81)	1.86(0.95–3.63)
Physical illness	31(24.4)	2.43(1.28–4.63)^**	66(20.4)	2.06(1.36–3.10) ^**	0.58(0.27–1.25)
Child maltreatment	64(52.5)	2.25(1.30–3.9) ^**	144(46.2)	1.98(1.44–2.72) ^***	1.79(0.86–3.74)
Adulthood traumatic events	87 (67.4)	2.51(1.34–4.69) ^**	173 (53.2)	1.30(0.95–1.78)	0.35(0.16–0.76) ^**
Impulsivity	61 (55.0)	1.34(0.77–2.32)	136 (43.5)	1.84(1.35–2.50) ^***	1.46(0.73–2.93)
Alcohol dependence	77 (65.3)	0.97(0.46–2.06)	48 (15.4)	2.61(1.52–4.51) ^**	1.16(0.44–3.07)
Drug misuse	50 (41.0)	1.81(1.00-3.26)	14 (4.3)	0.87(0.32–2.37)	0.06(0.02–0.16) ^***
Anxiety disorder	59(47.2)	3.13(1.69–5.79) ^***	98(29.8)	3.22(2.21–4.69) ^***	0.73(0.36–1.51)
Depression	27(21.6)	2.72(1.24–5.95) ^*	61(18.5)	1.00(0.65–1.55)	0.85(0.35–2.10)
Psychosis	21(17.2)	3.17(1.31–7.69) ^*	62(19.0)	2.05(1.28–3.30) ^**	1.52(0.61–3.80)
a: reference group, British young men without suicide attempt; b: reference group, Chinese young men without suicide attempt; c: reference group, British young men with suicide attempt. ref., reference; AOR, adjusted odds ratio; CI, confidence interval. , p < 0.05; , p < 0.01; **, p < 0.001. Variables were mutually adjusted. Missing data of each variable was presented in Table S1.

Association between nationality and suicide attempt

Chinese men were more likely to attempt suicide than British young men (Table 2), and this association increased after adjusting social-demographic factors (model 2), stress factors (model 3), impulsivity (model 4), and addictive disorders (model 5), but was attenuated by psychiatric disorders (model 6).

Table 2

Effect of nationality on suicide attempt.
	Model 1	Model 2	Model 3	Model 4	Model 5	Model 6
British	ref.	ref.	ref.	ref.	ref.	ref.
Chinese
AOR (95% CI)	1.27 (1.03 − 1.57) ^*	1.47 (1.15 − 1.87) ^**	1.64 (1.25 − 2.16) ^***	1.74 (1.31 − 2.32) ^***	2.15 (1.55 − 2.97) ^***	1.95 (1.40 − 2.73) ^***
Change of B(%)		57.9%	46.3%	25.6%	86.0%	-38.8%
Model 1: without adjustment; Model 2: adjusts for ethnicity, unemployment, education; Model 3: model 2 with additional adjustment for no close relationship, child maltreatment, adulthood traumatic events and physical illness; Model 4: model 3 with additional adjustment for impulsivity; Model 5: model 4 with additional adjustment for alcohol dependence and drug misuse disorder; Model 6: model 5 with additional adjustment for anxiety disorder, depression and psychosis. ref., reference; AOR, adjusted odds ratio; CI, confidence interval. , p < 0.05; , p < 0.01; **, p < 0.001.

Sub-typologies of suicide attempt among British and Chinese young men

Goodness of fit indices from 2-class to 5-class solutions are shown in Fig. 2a. The AIC, BIC, and aBIC values of 3-class solution were lower than that of the 2-class solution. There was a significant difference between 2-class solution and 3-class solution, but not between 3-class solution and 4-class solution. Meanwhile, entropy of the 3-class was higher than that of 4-class, indicating that 3-class solution had better goodness of fit compared with other solutions.

Figure 2b presents probabilities of response for factors included in 3-class solution. Class 1 included 121 (26.4%) young men with low endorsement of child maltreatment, adulthood traumatic events, drug misuse and high endorsement of anxiety, and was labelled “depressed/anxious”. The Class 2 was labelled “no psychiatric morbidity”, and included 201 (43.9%) men with no endorsement of psychiatric morbidity, but medium-level endorsement of adulthood traumatic events, impulsivity, and child maltreatment. The Class 3 included 136 (29.7%) men with high endorsement of lifetime traumatic factors, including child maltreatment and adulthood traumatic events, impulsivity, and anxiety, which was labelled “impulsive, trauma, psychopathology”.

The prevalence of Class 1 did not differ significantly between British and Chinese men (OR 95% CI: 0.65, 0.38–1.11, p > 0.05), while Chinese were more likely to be classified in Class 2 (OR 95% CI: 2.35, 1.52–3.64, p < 0.001) and less likely to be classified in Class 3 than British young men (OR 95% CI: 0.36, 0.24–0.56, p < 0.001). Table S3 presents class response percentages within variables and variables that discriminate between latent classes.

Table 3 compares different characteristics in each class between British and Chinese men with suicidal attempt. Compared to British, Chinese men showed lower prevalence of ethnic minorities and unemployment, in each class. In Class 1, Chinese men had higher prevalence of an older (25–34 years) age group but lower percentage of drug misuse. In Class 3, more Chinese men screened positive for psychosis and more British men for drug misuse. Chinese young men in Class 1 and Class 3 were less likely to receive mental health service than British young men.

Table 3

Differences within LCs among Chinese and British young men with suicide attempts (n = 458).
	Class 1 Depresssed/Anxious (121, 26.4%)			Class 2 No psychiatric morbidity (201, 43.9%)			Class 3 Impulsive, trauma, psychopathology (136, 29.7%)
	British 32(26.4%)	Chinese 89(73.6%)	OR (95% CI)	British 38(18.9%)	Chinese 163(81.1%)	OR (95% CI)	British 59(43.4%)	Chinese 77(56.6%)	OR (95% CI)
Age group
18–24	21(70.0)	35(39.8)	0.28(0.12–0.69)^**	14(40.0)	63(39.1)	0.96(0.46–2.04)	32(54.2)	35(46.7)	0.74(0.37–1.46)
25–34	9(30.0)	53(60.2)	ref.	21(60.9)	98(60.0)	ref.	27(45.8)	40(53.3)	ref.
Ethnicity (minority)	4(13.3)	3(3.4)	0.23(0.05–1.09)	7(20.0)	2(1.2)	0.05(0.01–0.26)^***	9(15.3)	1(1.3)	0.08(0.01–0.61)^*
Unemployment	13(46.4)	11(12.8)	0.17(0.06–0.45)^***	11(34.4)	21(13.0)	0.29(0.12–0.68)^**	32(56.1)	11(15.1)	0.14(0.06–0.32)^***
Education
High	6(20.0)	23(28.4)	ref.	11(31.4)	59(38.6)	ref.	14(24.6)	19(26.4)	ref.
Middle	22(73.3)	51(63.0)	0.61(0.22–1.69)	24(68.6)	83(54.2)	0.65(0.29–1.42)	42(73.7)	44(61.1)	0.77(0.34–1.73)
Low	2(6.7)	7(8.6)	0.91(0.15–5.58)	0	11(7.2)	NA	1(1.8)	9(12.5)	6.63(0.75–58.56)
Living alone	8(26.7)	16(18.2)	0.61(0.23–1.62)	3(8.6)	25(15.5)	1.96(0.56–6.90)	10(16.9)	13(17.8)	1.06(0.43–2.63)
No Close relationship	13(56.5)	33(44.0)	0.60(0.24–1.55)	5(16.7)	77(55.4)	6.21(2.25–17.17)^***	28(50.0)	2(42.0)	0.73(0.36–1.47)
Adulthood traumatic events	9(32.2)	28(30.0)	1.11(0.45–2.73)	21(60.0)	76(47.8)	0.61(0.29–1.29)	55(93.2)	65(87.8)	0.53(0.15–1.80)
Impulsivity	9(37.5)	23(27.4)	0.63(0.24–1.63)	11(33.3)	60(39.2)	1.29(0.58–2.85)	40(76.9)	50(70.4)	0.71(0.31–1.63)
Physical illness	8(26.7)	23(27.1)	1.02(0.40–2.61)	8(22.9)	23(14.5)	0.57(0.23–1.41)	15(26.3)	20(26.7)	1.02(0.47–2.22)
Child maltreatment	1(3.7)	9(10.3)	3.00(0.36–24.82)	13(37.1)	69(45.4)	1.41(0.66-3.00)	50(86.2)	63(92.6)	2.02(0.62–6.54)
Alcohol dependence	13(48.1)	25(30.5)	0.47(0.19–1.15)	0	1(0.6)	NA	12(21.8)	21(29.6)	1.51(0.66–3.41)
Drug misuse	7(24.1)	1(1.2)	0.04(0.004–0.32)^**	0	0	NA	43(72.9)	13(17.3)	0.08(0.03–0.18)^***
Anxiety disorder	19(67.9)	49(55.7)	0.60(0.24–1.46)	0	2(1.2)	NA	38(66.7)	46(61.3)	0.79(0.39–1.63)
Depression	13(46.4)	36(40.9)	0.80(0.34–1.88)	0	1(0.6)	NA	14(24.6)	23(30.7)	1.36(0.62–1.96)
Psychosis	7(25.9)	24(27.6)	1.09(0.41–2.90)	0	0	NA	14(24.6)	36(48)	2.84(1.33–6.03)^**
No psychiatric morbidity	0	3(3.4)	NA	33(100.0)	151(98.1)	NA	0	0	NA
Any mental health service	14 (48.3)	18 (22.5)	0.31(0.13–0.76)^*	6(19.4)	16(10.3)	0.48(0.17–1.33)	34(59.6)	16(22.5)	0.20(0.09–0.42)^***
^, p < 0.05; ^, p < 0.01; ^**, p < 0.001. ref: British. Missing data of each variable was presented in Table S1.

We found the prevalence of suicide attempts was higher among Chinese than UK men. Chinese young men who attempted suicide were less likely than British to be from an ethnic minority, unemployed, to have experienced adult trauma, and misused drugs, and more likely to be living alone and with no close relationships. Latent class analysis revealed a robust typology that applied to both countries but showed differences in prevalence: Class 1 “Depressed/Anxious” (with some showing alcohol dependence); Class 2 “No psychiatric morbidity” but with moderate levels of childhood maltreatment and adult life events; and Class 3 “Impulsive, trauma, multiple psychopathology,” an impulsive subgroup with childhood maltreatment/trauma persisting into multiple adult traumatic life events, multiple psychiatric morbidity, and addictions. Chinese men with suicide attempts were mainly characterized by membership of Class 2 “No psychiatric morbidity”; more British men were in Class 3 “Impulsive, trauma, multiple psychopathology”.

Prevalence of suicide attempts among British and Chinese men

Higher prevalence of suicide attempts among Chinese men is consistent with previous studies showing developing countries have higher rates than developed countries [12]. Differences did not disappear following multiple adjustments, suggesting nationality would be an independent associated factor. The higher prevalence among Chinese men was also higher than that reported in five other low- and middle-income countries at the time of the surveys [29]. However, WHO has reported that suicide rates among men have fluctuated in low- and middle-income countries in Western Pacific Regions [10]. It was of interest that Chinese men with suicidal behaviour were less likely to be from an ethnic minority and unemployed than British men. Ethnic minorities in China are indigenous rather than predominantly migrants from the mid-20th century onwards, as in UK. There are also specific government policies, including an ethnic minority assistance plan, and economic and work assistance for low-income households. However, factors associated with economic development may have contributed differently to higher prevalence in China despite having shown the fastest growing economy in the world, with sustained productivity and worker efficiency as the driving force. Increase in wealth is thought to be generally associated with improvements in mental health at the population level. However, these improvements are not evenly distributed. Certain subgroups (including young adult men) have been stressed by pressures of rapid urbanization and work migration. There are particular concerns over left behind children of work migrants acting as a vulnerability factor which affects 40% of Chinese children who remain with extended families or other careers, often in rural areas, with a growing literature showing adverse effects in adulthood on mental and physical health [30]. In this context, lacking protective close relationships and loneliness in adulthood among men in employment but experiencing other stressful experiences might lead to suicidal behaviour and indicated the need for accessing to support and counselling, particularly in Class 2.

Psychiatric disorder and suicide attempts

Some studies have reported a close relationship between depression and suicide attempts[2, 31], while others found this relationship varied by symptom severity, sex, and comorbid psychiatric disorders [31–33]. After adjustments, we found the association only among British men. This is consistent with a study conducted in rural China which found an association only among women [34].

The positive relationship between anxiety and suicide attempts among both Chinese and British men do not correspond to certain previous studies which tend to explain this on the basis of a relationship between suicide attempts and anxiety occurring in the context of depression [5]. However, it is consistent with a meta-analysis that found patients with anxiety were more likely to attempt suicide than patients without anxiety [35]. Furthermore, recent studies have found that college students and patients with anxiety were more likely to attempt suicide than those with major depressive disorder [36, 37]. However, few studies have been conducted in community samples. Our findings suggest that greater importance should be given to anxiety during clinical assessments and a mixed presentation of depression and anxiety (Class 1) appeared to characterise many young men. The prevalence of class 1 did not differ between British and Chinese young men. We also found psychosis was associated with suicide attempts among both British and Chinese young men, which was consistent with previous evidence that psychosis is a key associated factor [32, 33, 38–40]. These results indicate the importance of screening individuals attempting suicide for characteristics of class 1 due to their high risk and need for urgent psychiatric treatment, including consideration of need for hospitalisation in severe cases.

Reported use of mental health services showed that more British young men with suicidal behaviour received these than Chinese men. Two factors may explain these differences: firstly, there were shortages of mental health services in China before 2013, resulting in the government of China promulgating the National Mental Health Work Plan (2015–2020) [41]. Secondly, although the stigma of mental illness is a worldwide problem [42], in China it may be a more serious problem because of the vital role of “face” in Chinese culture. This may result in delay in seeking help. Reducing stigma of mental disorder and self-harm is important for encouraging treatment-seeking and obtaining professional help for prevention.

Different sub-types of suicide attempt and associated factors

Absence of psychiatric morbidity characterised Class 2 and was more prevalent among Chinese men who experienced traumatic events in adulthood. This pattern was reported in the past among young women in China, but is now less common [43]. This was consistent with a psychological autopsy study that found that the high suicide rate was related to high stress in the absence of mental disorders [43]. In contrast, British men were more likely to show features of impulsivity, lifetime trauma, and psychopathology, in Class 3. These results indicated that for Chinese men, interventions should concentrate on increasing resilience to cope with traumatic events. For British men, the additional importance of reducing misuse of drugs and alcohol.

More than half of Chinese men in class 2 were unable to develop a close relationship. These results imply fostering socio-emotional skills might be a target of suicide prevention. The fierce competition for education and employment in the general population can place a heavy burden on students necessary to continue the economic improvements that have transformed the economy. This situation might lead to the neglection of fostering skills to cope with pressure, which in turn reduces their ability to develop close relationships. Improving socio-emotional life skills, an effective, evidence-based WHO recommended intervention [44], may be a helpful intervention for some men in Class 2. Although China has not developed a regional or national plan for suicide prevention, psychological crisis centres have now been established, hand a hotline for obtaining psychological aid and accessing crisis intervention teams [10].

Strengths and Limitations

This was a community-based survey and adopted the method of multi-stage random sampling, which avoids the selection bias in clinical sample surveys. The samples of this study were representative and sufficiently large to provide statistical power. Few studies have used the same research method to conduct investigations in Eastern and Western countries at the same time. Our research adopted the same research method, including the same questionnaire and diagnostic instruments. However, there are certain limitations. First, we conducted surveys in two countries, but the survey of China was restricted to Chengdu City and certain semi-urban areas and rural villages located in the Western area of China. However, the samples were weighted to be representative of this area. Second, although the source of information was self-report and subjects may conceal their negative behaviours, such as substance use, we conducted anonymous survey to reduce the possibility of concealing information, thereby improving the reliability of the survey results. Finally, the diagnosis of psychiatric disorder was not confirmed by a psychiatrist. However, we used standardised self-report research instruments based on DSM-IV to improve diagnostic reliability.

We have developed a typology of suicide attempts among young adult men and these appeared robust across two very different cultural contexts despite differences in prevalence in each location. These differences appeared to result from differences in prevalence of social associated factors in China and the UK, although these associated factors were generally similar. Future research could apply the three-class typology in clinical practice if it can be established as having clinical efficacy in assessing risk and if it determines clinical management. It will also be important to establish through future research whether belonging to a particular class determines firstly, long-term outcome, and secondly, effectiveness of preventive interventions for suicide.

Supplementary Materials

Supplementary Methods and Materials. Table S1 Patterns of missing values in British and Chinese young men. Table S2 Social factors, impulsivity, stress factors, addictive disorders and psychiatric morbidity among Chinese and British young men with suicide attempt. Table S3 Cluster/class response percentages within class (n = 458).

Acknowledgements

The authors would like to acknowledge the efforts of the research team and the kindness of the participants for their participation.

Authors’ contributions

JM.H., J.C. and XC.C. designed the study. JM.H. and J.C. were responsible for data collection. XC.C. performed the analyses and drafted the manuscript. YM.Z. gave support for the data analyses and JJ.X. contributed to the interpretation of results. YF.Q., XT.Y., YW. H. contributed to prepare the tables and supplementary materials. All authors commented on and approved the final manuscript.

Funding

This study was supported by the National Institute for Health Research (NIHR) under the Programme Grants for Applied Research (RP-PG-0407-10500 to Jeremy Coid and Jun-Mei Hu) in Britain and China, the National Natural Science Foundation of China (XCC, Grant Number: 82302119), the National Postdoctoral Science Foundation of China (XCC, Grant Number: 2020TQ0219) and the Sichuan Science and Technology Program (XCC, Grant Number: 2023YFS0291). The funding sources had no role in the study design, in the interpretation of data, and in the writing of the manuscript.

Data Availability Statement

The data that support the findings of this study are available from JM.H. and J.C., upon reasonable request.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Hefei Fourth People’ Hospital (HSY-IRB-YJ-LWTG-YT003). All participants provided written informed consent. All procedures were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration.

Ethnical standards

Consent for publication

Not applicable.

Competing interests

All authors declare that there is no conflict of interests.

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Cross-national comparison of three latent classes of young men who attempted suicide in China and Britain

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Method

Study population

Measures

Socio-demographic variables

Mental health assessment

Suicide attempt

Lifetime Traumatic events

Impulsivity

Statistical analyses

Results

Prevalence of suicide attempt

Associated factors of suicide attempt among British and Chinese young men

Association between nationality and suicide attempt

Sub-typologies of suicide attempt among British and Chinese young men

Discussion

Prevalence of suicide attempts among British and Chinese men

Psychiatric disorder and suicide attempts

Different sub-types of suicide attempt and associated factors

Strengths and Limitations

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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